Tics Moderate Sertraline, but Not Cognitive-Behavior Therapy Response in Pediatric Obsessive-Compulsive Disorder Patients Who Do Not Respond to Cognitive-Behavior Therapy

Pediatric Treatment-Resistant Obsessive Compulsive Disorder: Treatment Options and Challenges

Pediatric obsessive-compulsive disorder (OCD) is a chronic, potentially debilitating psychiatric condition. Although effective treatments exist, at least 10% of youth do not achieve remission despite receiving first-line treatments. This article reviews the extant, albeit limited, evidence supporting treatment approaches for youth with treatment-resistant OCD. A literature search for articles addressing pediatric treatment-resistant OCD was conducted through April 11, 2024. These results were augmented by searching for treatment-resistant OCD in adults; treatment strategies discovered for the adult population were then searched in the context of children and adolescents. In general, intensive treatment programs and antipsychotic augmentation of an antidepressant had the most substantial and consistent evidence base for treatment-resistant youth with OCD, although studies were limited and of relatively poor methodological quality (i.e., open trials, naturalistic studies). Several pharmacological approaches (clomipramine, antipsychotics [e.g., aripiprazole, risperidone], riluzole, ketamine, D-cycloserine, memantine, topiramate, N-acetylcysteine, ondansetron), largely based on supporting data among adults, have received varying levels of investigation and support. There is nascent support for how to treat pediatric treatment-resistant OCD. Future treatment studies need to consider how to manage the significant minority of youth who fail to benefit from first-line treatment approaches.

Obsessive-Compulsive Disorder in Children and Adolescents

Obsessive-compulsive disorder (OCD) in children and adolescents is a neurobehavioral condition that can lead to functional impairment in multiple domains and decreased quality of life. We review the clinical presentation, diagnostic considerations, and common comorbidities of pediatric OCD. An overview of the biological and psychological models of OCD is provided along with a discussion of developmental considerations in youth. We also describe evidence-based treatments for OCD in childhood and adolescence, including cognitive behavioral therapy (CBT) with exposure and response prevention (ERP) and pharmacotherapy. Finally, research evaluating the delivery of CBT in different formats and modalities is discussed, and we conclude with suggestions for future research directions.

Co-Occurring Anxiety in Youth with Tic Disorders: A Review

Objective: To review the current state of the literature regarding anxiety symptoms and anxiety disorders in chronic tic disorder (CTD). Results: We conducted a literature search on anxiety and tic disorders. Anxiety symptoms and anxiety disorders are common in youth with CTD, with ∼30%-50% of youth with CTD having at least one co-occurring anxiety disorder. Tics often improve by young adulthood but anxiety symptoms tend to persist, or worsen, over time. Anxiety and tics are closely related, but the exact nature of their relationship is poorly understood. We discuss some potential ways in which anxiety and tics are linked with an emphasis on the underlying brain circuitry involved. The relationship between anxiety and tics may be related to the premonitory urge. In addition, stress hormones may link anxiety and tics. Individuals with CTD have greater activation of their hypothalamic-pituitary-adrenal system in response to acute stress. We also review the impact of anxiety on youth with CTD and approaches to management of anxiety in youth. Conclusions: Anxiety is common in youth with CTD, is associated with more severe CTD, and can adversely affect a child's function. Thus, it is important to identify anxiety disorders in CTD and manage them appropriately.

Specialty knowledge and competency standards for pharmacotherapy for pediatric obsessive-compulsive disorder

Evidence based treatments for pediatric Obsessive-Compulsive Disorder (OCD) are delivered with varying levels of expertise. This paper is part of the phase two series by the International OCD Accreditation Task Force (ATF) to advance a standardized high level of care globally. This paper presents specific knowledge and competencies recommended for specialized practice for pediatric psychopharmacologists working with OCD, developed by an international group of clinicians with extensive expertise in assessment and treatment of OCD. Tabulated knowledge and competency standards are operationalized as clinician abilities with specification of evidence for each standard. The distinction between current practice guidelines and ATF standards is discussed. Drug treatment has a solid evidence base. However, it should not be applied isolated, but informed by broad competence in general child and adolescent psychiatry and pediatrics. Other treatment relevant areas such as specialty CBT, family functioning, developmental issues, and neurobiology require consideration. Drug treatment includes several phases with varying degrees of evidence: Starting up medication, titration to maximum tolerated dose, maintenance, termination, and relapse prevention. In complex cases, pharmacotherapy with weak evidence may be needed to target symptoms and/or co-morbidity. The ATF knowledge and competency standards presented will be reviewed and updated commensurate with research.

Anxiety Symptoms Differ in Youth With and Without Tic Disorders

We compared anxiety symptoms in youth with and without tic disorders by comparing scores on the Multidimensional Anxiety Scale for Children (MASC) in youth with tic disorders to those in a concurrent community control group and in a group of treatment-seeking anxious youth from the Child/Adolescent Anxiety Multimodal Study (CAMS). Data from 176 youth with tic disorders, 93 control subjects, and 488 CAMS participants were included. Compared to youth with tic disorders, controls had lower total MASC scores (p < 0.0001) and CAMS participants had similar total MASC scores (p = 0.13). Separation Anxiety (p = 0.0003) and Physical Symptom (p < 0.0001) subscale scores were higher in youth with tic disorders than in CAMS participants. We conclude that the anxiety symptom profile differs in youth with and without tic disorders, which may have important implications for targeting treatment of anxiety in youth with tic disorders.

A population-based family clustering study of tic-related obsessive-compulsive disorder

In the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), obsessive-compulsive disorder (OCD) included a new "tic-related" specifier. However, strong evidence supporting tic-related OCD as a distinct subtype of OCD is lacking. This study investigated whether, at the population level, tic-related OCD has a stronger familial load than non-tic-related OCD. From a cohort of individuals born in Sweden between 1967 and 2007 (n = 4,085,367; 1257 with tic-related OCD and 20,975 with non-tic-related OCD), we identified all twins, full siblings, maternal and paternal half siblings, and cousins. Sex- and birth year-adjusted hazard ratios (aHR) were calculated to estimate the risk of OCD in relatives of individuals with OCD with and without comorbid tics, compared with relatives of unaffected individuals. We found that OCD is a familial disorder, regardless of comorbid tic disorder status. However, the risk of OCD in relatives of individuals with tic-related OCD was considerably greater than the risk of OCD in relatives of individuals with non-tic-related OCD (e.g., risk for full siblings: aHR = 10.63 [95% CI, 7.92-14.27] and aHR = 4.52 [95% CI, 4.06-5.02], respectively; p value for the difference < 0.0001). These differences remained when the groups were matched by age at first OCD diagnosis and after various sensitivity analyses. The observed familial patterns of OCD in relation to tics were not seen in relation to other neuropsychiatric comorbidities. Tic-related OCD is a particularly familial subtype of OCD. The results have important implications for ongoing gene-searching efforts.

Psychiatric Diseases in Children and Adolescents

Pharmacotherapy of psychiatric illnesses in children and adolescents has grown significantly over the last few decades. However, the body of research examining pharmacological treatments for psychiatric illnesses is much smaller in children and adolescents than it is in adults. As most treatments for psychiatric disorders are more effective if started early in the course of illness, treatment options for youth are especially important in order to ensure better treatment outcomes. This chapter discusses currently approved medications to treat psychiatric disorders in children and adolescents. Research on medications that may be effective treatments but are not yet FDA approved is also discussed. The medications are broken down into major categories used in youth with psychiatric disorders including antidepressants, mood stabilizers, ADHD medications, and antipsychotics.

Diagnostic Issues in Early-Onset Obsessive-Compulsive Disorder and their Treatment Implications

BACKGROUND

The lifespan approach and recent shift in the conceptualization of Obsessive- Compulsive Disorder (OCD) promoted by the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM5) along with novel insights into the pathogenesis of this heterogeneous disorder are driving the development of new outcome measures and new treatments for a disease that, on the other hand, is characterized by high rates of refractoriness.

OBJECTIVE AND METHODS

The aim of this review is to provide a discussion of the translational evidence about Early Onset OCD (EO) in compliance with a neurodevelopmental and RdoC perspective.

RESULTS AND CONCLUSION

EO might be considered the neurodevelopmental subtype of OCD. Indeed there is evidence that different clusters of symptoms and dimensions at an early stage predict different trajectories in phenotype and that distinct neurocircuit pathways underpin the progression of the disorder. Despite the development of high refractoriness in the course of the disorder, evidence suggests that EO may be particularly treatment responsive in the early stages, thus showing the need for early recognition and additional recovery oriented studies in this subgroup. Consistent with the neurodevelopmental perspective, immunity and glutamate neurotransmission are emerging as novel pathways for parsing out the neurobiology of OCD, the EO form, in particular, supporting the implementation of new multisystemic models of the OCD phenotype. Brain connectivity patterns, immune and microbiome profiles are standing out as promising areas for biomarkers with the potential for targeted personalized therapies in EO.

Systematic review of co-occurring OCD and TD: Evidence for a tic-related OCD subtype?

OBJECTIVE

The aim of this review is to summarize the current knowledge of associated features of co-occurring obsessive-compulsive disorder (OCD) and tic disorders (TD) and to critically evaluate hypotheses regarding the nature of their comorbidity.

METHOD

We conducted a systematic review following PRISMA guidelines. To this aim, the PubMed, PsychInfo and ISI Web of Knowledge databases were searched up to August 30, 2018. For gender and age-of-onset we additionally conducted meta-analyses.

RESULTS

One hundred eighty-nine studies met inclusion criteria. We substantiate some acknowledged features and report evidence for differential biological mechanisms and treatment response. In general, studies were of limited methodological quality.

CONCLUSIONS

Several specific features are reliable associated with co-occurring OCD + TD. The field lacks methodological sound studies. The review found evidence against and in favor for different hypotheses regarding the nature of comorbidity of OCD and TD. This could indicate the existence of a stepwise model of co-morbidity, or could be an artefact of the low methodological quality of studies.

Moderators and predictors of response to cognitive behaviour therapy for pediatric obsessive-compulsive disorder: A systematic review

We report a systematic review of moderators of CBT efficacy for pediatric OCD relative to other treatments. CENTRAL, MEDLINE, EMBASE, CINAHL, and PsycINFO were searched for RCTs reporting on effect moderation for CBT outcomes. Five studies (N = 365) examined 17 variables with three significant moderators identified. Compared to pill-placebo, CBT monotherapy was not effective for children with a family history of OCD but was for those without a family history. For children with a family history, CBT plus sertraline efficacy was attenuated but remained significant. For children with tics, CBT but not sertraline remained superior to pill-placebo. For non-responders to initial treatment with CBT, continuing CBT was inferior to commencing sertraline for those with tics but was not different for those without tics. A supplementary review identified older age, symptom and impairment severity, co-morbidity and family accommodation as consistent predictors of a poorer outcome to CBT. Current evidence for moderation effects is post-hoc, from single RCTs, has small Ns and requires replication. The review identifies family history of OCD and the presence of tics as factors requiring further examination in properly conducted trials and about which clinicians need to show care in their treatment recommendations.

Pediatric obsessive-compulsive disorder with tic symptoms: clinical presentation and treatment outcome

Some studies have shown that children and adolescents with obsessive-compulsive disorder (OCD) and co-morbid tics differ from those without co-morbid tics in terms of several demographic and clinical characteristics. However, not all studies have confirmed these differences. This study examined children and adolescents with OCD and with possible or definite tic specifiers according to the DSM-5 in order to see whether they differ from patients without any tic symptoms regarding clinical presentation and outcome of cognitive behavioral therapy (CBT). The full sample included 269 patients (aged 7-17) with primary DSM-IV OCD who had participated in the Nordic Long-term Treatment Study (NordLOTS). Symptoms of tics were assessed using the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS-PL). One or more tic symptoms were found in 29.9% of participants. Those with OCD and co-morbid tic symptoms were more likely male, more likely to have onset of OCD at an earlier age, and differed in terms of OCD symptom presentation. More specifically, such participants also showed more symptoms of OCD-related impairment, externalization, autism spectrum disorder (ASD), social anxiety, and attention-deficit/hyperactivity disorder (ADHD). However, the two groups showed no difference in terms of OCD severity or outcome of CBT. Children and adolescents with OCD and co-morbid tic symptoms differ from those without tic symptoms in several aspects of clinical presentation, but not in their response to CBT. Our results underscore the effectiveness of CBT for tic-related OCD.

CLINICAL TRIALS REGISTRATION

Nordic Long-term Obsessive-Compulsive Disorder (OCD) Treatment Study; www.controlled-trials.com ; ISRCTN66385119.

[New developments in the psychotherapeutic and pharmacological treatment of pediatric obsessivecompulsive disorder]

Den Goldstandard in der Behandlung von Zwangsstörungen im Kindes- und Jugendalter stellen die kognitiv-behaviorale Therapie sowie die Medikation mit selektiven Serotonin-Wiederaufnahmehemmern dar. In den letzten Jahren wurden vermehrt auch alternative psychotherapeutische und v. a. psychopharmakologische Behandlungsstrategien untersucht, die möglicherweise bei therapieresistenten Zwangsstörungen erfolgreich sein könnten. Die vorliegende Übersichtsarbeit fasst diese neuen Entwicklungen zusammen, wobei ein Schwerpunkt auf expositionsbezogene psychotherapeutische bzw. pharmakologische Ansätze im glutamatergen System gelegt wurde. Hinsichtlich neuer pharmakologischer Behandlungsoptionen bei Kindern und Jugendlichen unterstreicht die derzeitige Datenlage, v. a. im Hinblick auf den Grad der nachgewiesenen Evidenz sowie mögliche unerwünschte Nebenwirkungen, die Bedeutung einer optimal durchgeführten Kombinationstherapie. Dabei kann diese einer Monotherapie mit kognitiv-behavioraler Therapie im Einzelfall überlegen sein. Eine grundsätzliche Überlegenheit der Kombinationstherapie ist derzeit allerdings nicht nachgewiesen.